A patient with known bipolar disorder was admitted to the mental health unit for medication adjustment.
The patient in the scenario was being treated for depression and the nurse will monitor for thoughts of suicide. Indicate with an X which behavior may indicate suicidal ideation and which is unrelated.
Patient remarking that the patient had a plan and was intent on carrying it out
Poor hygiene
Comments from the patient such as, “Things will get better after I’m gone.”
Pacing in the room
Excessive appetite
Sleeping throughout the day
Patient’s relative indicated that the patient has recently given away a collection of expensive dishes
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}
Patient remarking that the patient had a plan and was intent on carrying it out → Significant Finding
Expressing a specific plan and intent is a major suicide risk indicator, requiring immediate safety interventions.
Poor hygiene → Unrelated Finding
Poor hygiene can reflect depression, but it is a nonspecific finding and does not directly indicate imminent suicidal intent.
Comments from the patient such as, “Things will get better after I’m gone.” → Significant Finding
Statements implying hopelessness or anticipating absence strongly suggest suicidal ideation and need urgent assessment.
Pacing in the room → Unrelated Finding
Pacing may indicate anxiety, restlessness, or agitation, but it is not a direct marker of suicidal ideation.
Excessive appetite → Unrelated Finding
Appetite changes occur with mood disorders, but alone they do not indicate suicidal intent.
Sleeping throughout the day → Unrelated Finding
Hypersomnia is common in depression, but by itself, it is not a red-flag suicidal behavior.
Patient’s relative indicated that the patient has recently given away a collection of expensive dishes → Significant Finding
Giving away prized possessions is a common pre-suicide behavior, showing preparation and finality.
Take-home Points:
- Direct verbal cues and a plan are the strongest indicators of suicide risk.
- Behavioral clues like giving away possessions signal possible preparation for suicide.
- Depressive symptoms (sleep, appetite, hygiene) raise concern but are not definitive for suicidal ideation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Selective serotonin reuptake inhibitors (SSRIs) are a first-line treatment for depression and anxiety disorders. They act by inhibiting the reuptake of serotonin, thereby increasing its availability in the synaptic cleft and enhancing mood regulation. Knowing which drugs belong to this class is essential for safe nursing practice.
A. paroxetine (Paxil)
– Paroxetine is an SSRI, along with fluoxetine, sertraline, citalopram, and escitalopram. These drugs are widely prescribed because they are effective, well tolerated, and have fewer cardiovascular and anticholinergic effects compared to older antidepressants. Patients should be counseled that benefits may take several weeks to appear and to watch for adverse effects such as sexual dysfunction and insomnia.
B. amitriptyline (Elavil)
– Amitriptyline is a tricyclic antidepressant (TCA). TCAs work by blocking the reuptake of both serotonin and norepinephrine but are less selective than SSRIs. They carry risks of sedation, orthostatic hypotension, and anticholinergic effects (dry mouth, urinary retention, constipation).
C. divalproex sodium (Depakote)
– Divalproex is a mood stabilizer and anticonvulsant, commonly prescribed for bipolar disorder and seizure disorders. It does not act on serotonin reuptake and therefore is not classified as an SSRI.
D. bupropion HCl (Wellbutrin)
– Bupropion is an atypical antidepressant that inhibits the reuptake of dopamine and norepinephrine. It is useful in depression and smoking cessation but is not serotonergic and carries a risk of seizures at higher doses.
Take-Home Points:
- SSRIs: fluoxetine, paroxetine, sertraline, citalopram, escitalopram.
- SSRIs are first-line for depression/anxiety due to better tolerability.
- Always assess for serotonin syndrome and suicidal ideation when initiating therapy.
Correct Answer is C
Explanation
Tricyclic antidepressants (TCAs) such as imipramine strongly block histamine and muscarinic receptors, leading to pronounced anticholinergic and sedative effects. In older adults, these adverse effects are magnified due to decreased drug clearance and sensitivity of the central nervous system, making fall precautions and safety interventions critical.
C. Drowsiness and sedation – TCAs have strong sedative properties from histamine receptor blockade. In elderly clients, this greatly increases fall risk, confusion, and potential injuries, making it the most important nursing precaution.
A. Dry mouth and photosensitivity – These can occur with TCAs but are not the most dangerous in older adults compared to sedation and fall risk.
B. Anxiety, headaches, insomnia – These are more common with SSRIs and SNRIs, not typically emphasized with TCAs like imipramine.
D. Urinary frequency – TCAs more often cause urinary retention due to anticholinergic effects, not increased frequency.
Take-Home Points:
- TCAs such as imipramine can cause strong sedation, especially problematic in older adults.
- Fall risk and confusion are major nursing concerns with TCAs in the elderly.
- Anticholinergic side effects are common, but sedation and safety issues take priority in this age group.
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